The Risk Factors of Self-Management Behavior among Chinese Stroke Patients

Background Stroke is associated with a high number of disability-adjusted life years globally, so long-term care is necessary and important for those survivors, so self-management is becoming a more significant concept in stroke rehabilitation. Methods Ischemic stroke patients (n = 354) were enrolled from the outpatient department of Neurology in West China Hospital from September 2018 to December 2019. The general demographic and disease-related data of stroke patients were collected. The stroke self-efficacy questionnaire (SSEQ), the brief cognition questionnaire (BIPQ), and the stroke self-management scale (SSMS) were used to collect data on self-efficacy, disease cognition, and self-management behavior separately. The chi-square test, Fisher exact test, independent sample t-test, and Mann–Whitney U test were used for comparison among groups. The logistic regression analysis was used to explore the independent risk factors of the different levels of self-management behavior in stroke patients. Results The score of self-management among Chinese stroke patients was 151.07 ± 18.53. Multivariate analysis showed that the way of paying medical expenses (OR = 3.215, 95% CI (1.130, 7.769)), self-management efficacy (OR = 2.467, 95% CI (1.534, 3.968)), health education before discharge (OR = 2.354, 95% CI (1.457, 3.802)), age (elder) (OR = 2.060, 95% CI (1.265, 3.355)), educational level (OR = 1.869, 95% CI (1.169, 2.988)), and mRS score (OR = 1.850, 95% CI (1.129, 3.031)) were statistically significant (P  <  0.05). Conclusions The self-management behavior of Chinese stroke patients was at the middle level. Patients with medical insurance, high self-efficiency of management, and better limb function may have better self-management behavior. Besides, patients with a high educational level who accept health education before discharge may also have better self-management behavior. For patients, it is important to know this disease in the right way and set up the faith to take care of themselves independently gradually. For medical staff, it is necessary and important to give all patients health education about self-management before discharge. It is urgent to call for attention to this disease, and the government and all of society should give more support to stroke patients.


Introduction
As one of the most important cerebrovascular diseases, stroke has been the second-most fatal and third-most disabling disease in the world, but it has been the leading cause of death in China in recent years, where almost one-ffth of the world's population resides [1][2][3]. A newly performed comprehensive assessment of the trends in China from 2013 to 2019 found the prevalence of stroke in China and most provinces has continued to increase in the past 7 years (2013-2019) and warrants a broad-based nationwide strategy for improved prevention as well as greater eforts in screening and more efective and afordable interventions [4]. Although in-hospital outcomes have improved because of a greater availability of evidence-based therapies and supportive care, adherence to secondary prevention strategies and long-term care are inadequate [5]. According to the scientifc statement for health care professionals from the American Heart Association, there is strong evidence that self-management is efective in achieving the goals of the treatment plan and cannot be ignored [6]. Furthermore, behavior, especially self-management or self-care behavior, is thought to be the predominant factor afecting illness and disease. Understanding self-management, knowing the risk factors of stroke, having a healthy diet consisting of physical activity and exercise, adhering to medication, and correcting unhealthy lifestyles are part of the self-management behavior of stroke patients. However, in China, medication adherence is poor among community-dwelling patients [7], and the necessary monitoring of stroke patients after discharge is scarcely in practice; besides, about 30 to 60% of patients do not have access to rehabilitation in hospitals [5]. Despite all this, it is hard to know the whole level of selfmanagement behavior from single aspects of selfmanagement behavior among Chinese stroke patients. Terefore, the purpose of this study is to describe the actual situation of Chinese stroke patients as a whole and explore the risk factors of self-management behavior.

Study Design and Participants.
Stroke patients were continuously enrolled in West China Hospital, Sichuan University, from September 2018 to December 2019 and evaluated face-to-face at a clinic of the neurology department in this prospective cross-sectional study. Te study was approved by the Ethics Committee of West China Hospital (2018496) and registered before conducting the research (ChiCTR1900022959). We obtained written informed consent from all patients before the assessment. All stroke patients were diagnosed according to Chinese guidelines for the diagnosis and treatment of acute ischemic stroke in 2018. Te inclusion criteria for ischemic stroke patients are detailed as follows: (1) age more than 18 years old; (2) no serious aphasia, speech expression, or communication barriers, can communicate with the researcher through words or body language; (3) time of stroke onset is known more than 2 weeks; (4) the modifed Ranking score less than 3 and Barthel index score more than 20; (5) informed consent and volunteer to participate in the study. Patients were excluded if they met any of the following conditions: (1) with moderate or severe encephalatrophy; (2) with cognitive impairment or mental illness previously; (3) with malignant tumor, hematonosis, serious heart, liver, lung, and kidney disease; (4) dwelling in rehabilitation institutions; and (5) quitting during the investigation process.  [8]. Te revised Chinese version of the SSEQ includes 2 dimensions and 11 items, including items on activity function efcacy (6 items) and self-management efcacy (5 items). Te total Cronbach's α coefcient of the scale is 0.969 [9]. Each item is scored by 0-10 grades. Te higher score in each dimension indicates better self-efcacy, respectively. In order to classify the efcacy, we used the standard score index to make it comparable: the standard score index � (the actual score of this dimension/the highest score of the dimension) * 100%; the score index less than 60% indicates poor efcacy, 60 to 80% indicates medium efcacy, and more than 80% indicates good efcacy.

Disease Cognition Data.
With the in-depth study of disease cognition, Broadbent evolved from the revised cognition questionnaire compiled by Weinman et al. [10] and Rona et al. [11], and the brief cognition questionnaire (BIPQ) was completed in 2006. Te questionnaire includes 8 dimensions (items 1 to 8): consequences, timeline, personal control, treatment control, identity, concerns, understanding, and emotional response. Item 9 of the BIPQ is an open question that explores causal representation and assesses the top three causes of stroke. Te higher score means the more negative disease cognition, which can quickly and conveniently evaluate the patients' status of disease cognition [12,13].

Modifed Rankin Scale (mRS).
Warlow designed mRS based on Rankin scale in 1988 to evaluate the disability level after stroke comprehensively. In this study, mRS was used to measure the ability to live independently and was divided into 7 levels: 0 for asymptomatic (no need for assistance), 5 for severe disability (complete dependence), and 6 for death. Te scale has been widely used and has good reliability and validity [14].

Te Barthel Index (BI).
Te Barthel index (BI) was published in 1965 by American scholars Florence Mahoney and Dorothea Barthel. It includes 10 items with a full score of 100. Te lower the score is, the more serious the disability is, and the more help is needed. 0-20 points refect extremely serious functional defects; 25-45 points refect serious dysfunction; 50-70 points refect moderate dysfunction; 75-95 points refect mild dysfunction; and 100 points refect complete self-care [15].

Self-Management Data.
Te stroke self-management scale (SSMS) was designed by Wang Yanqiao, a Chinese scholar, on the basis of the self-management connotation and other chronic disease self-management behavior scales. It has seven dimensions, including disease management, medication management, diet management, daily life management, emotion management, social function and interpersonal management, rehabilitation, and exercise management. Out of the total of 50 items, 49 items were scored using a 5-level scoring method (1-5 points). In the dimension of food management, 1 item scored 1-10 points. Te higher total score shows better self-management behavior. Te total Cronbach's α coefcient of the scale is 0.835, the content validity is 0.95, and the structural validity is 0.594-0.771 [16]. In order to compare the scores of diferent dimensions, the standard score index is used. Te standard score index � (the actual score of this dimension/the highest score of the dimension) * 100%, the standard score index less than 60% indicates poor self-management, 60 to 80% indicates the medium self-management, and more than 80% indicates the good self-management.

Study Sample
Size. PASS 11.0 software (NCSS., Rijswijk, Te Netherlands) was used to calculate the sample size. 318 cases that need to be investigated. Assuming 10% nonresponse rate, the fnal sample size became 354.
Te classifcation data were described by frequency and proportion. Te continuous data were described by means and standard deviation if they conform to normal distribution. If they do not conformed to a normal distribution, they are described by means of median and interquartile range.
Classifcation data were conducted by chi-square test or Fisher exact test. Continuous data were conducted by independent sample t-test or Mann-Whitney U-test. Te variables of P < 0.15 in single factor analysis and those closely related to self-management in clinical settings served as the independent variables for binary logistic regression analysis. Box Tidwell was used to test whether the logit conversion value between a continuous independent variable and a dependent variable is linear.

Data Collection.
In this study, 400 questionnaires were sent out, 367 questionnaires were taken back, the response rate was 91.75%, 13 invalid questionnaires were eliminated, the remaining 354 valid questionnaires were left, and the efective rate was 96.45%. Please see Figure 1 research fow chart for details. Table 1, this study included 354 efective stroke patients, of whom 108 (30.5%) were women and 246 (69.5%) were men, with an average age of 61.16 ± 13.01 years.

Diseases-Related Characteristics.
Of the 354 patients who were included, 192 (54.2%) patients never smoke, 107 (30.2%) patients have quit smoking, and 206 (58.2%) patients never drink alcohol. Te most common chronic disease was hypertension (58.8%). In this study, 50.8% of patients had no primary caregiver. Te most common sequelae were motor dysfunction (27.1%). 46.9% of patients did not receive self-management health education before discharge. See Table 2 for details.
Te disability level and activities of daily living are shown in Table 3. Of the 354 patients who were included, 75.7% patients in our study could completely self-care.

Descriptive Analysis of Self-Management Behavior of Stroke Patients.
According to the Shapiro-Wilk normal test, the data conformed to the normal distribution. Te score of the SSMS was 151.07 ± 18.53; 210 patients (59.3%) had poor self-management behavior, 141 patients (39.8%) were at medium level, and 3 patients (0.8%) had good selfmanagement behavior. See Table 4 for details.

Single Factor Analysis.
Since only three patients in the good level group, so we combined the good and middle group. Comparing the diference of self-management behavior between middle-high-level group and low-level group. Tables 5 and 6 showed that the educational level, average monthly income of the family, payment method of medical expenses, health education of self-management before discharge, SSEQ self-management efcacy dimension, and the score of SSEQ and BIPQ between the two groups were statistically signifcant (P < 0.05).
3.6. Multivariable Analysis. 21 items were included in the linear test model, and the signifcance level after Bonferroni correction was 0.0024. Te linear test results showed that there is a linear relationship between all the continuous independent variables and the logit conversion value of the dependent variable.
Finally, the logistic model was statistically signifcant (χ 2 � 53.876, P < 0.001) ( Table 7). Te model can correctly classify 66.9% of the research objects. Among the variables included in the model were statistical signifcance (P < 0.05) in terms of payment method for medical expenses, SSEQ self-management efcacy, self-management health education before discharge, age (old age), educational level, and mRS score. See Table 7 for details.

Discussion
Tis study reported the actual whole status of selfmanagement behavior and studied the risk factors of selfmanagement in Chinese stroke patients. Te results

International Journal of Clinical Practice
Enrolled Ischemic stroke outpatients N=1081 Excluded case with serious aphasia, speech expression and communication barrier, n=135 Excluded case with malignant tumor disease, n=79 Not included (mRS >3 and BI<20) , n=102 Not included (time of stroke onset is known less than 2 weeks ) , n=41 Not consent or volunteer to participate, n=317 Not included (less than18 years old), n=7 Included patient N=400 (100%) Quit during the investigation process, n=33 Enrolled Ischemic stroke outpatients N=367 (91.5%) Invalid questionnaires, n=13 Completed case N=354 (88.5%) Figure 1: Research fow chart. indicated that the payment way of medical expense, selfmanagement efciency, health education about selfmanagement before discharge, age, educational level, and mRS score were independently infuencing factors of selfmanagement behavior. Although Healthy China 2030 emphasized the importance of structuring a better health security system, especially for chronic diseases [17], patients still need to pay a part of their medical bills, even if they have medical insurance. Our study shows socioeconomic factors such as inadequate health insurance may have a negative impact on self-management behavior. Our study is consistent with the national registry study in China, which demonstrated that health insurance status was signifcantly associated with 1year outcomes for patients with stroke. Patients who are covered by the New Rural Cooperative Medical Scheme, which has lower reimbursement rates than the Urban Basic Medical Insurance Scheme [18]. However, stroke is a leading cause of long-term disability globally and a resourceintensive disease, both directly and indirectly [19]. A Sweden study based on regional administrative systems found that the monetary burden of stroke is very high, and patients who are afliated with stroke may also have a socioeconomic gradient in the utilization of Swedish health insurance [20]. Prior studies have demonstrated that insurance status is an independent predictor of patient safety events after stroke.

International Journal of Clinical Practice
Te absence of private insurance is associated with higher mortality, longer lengths of stay, and worse clinical outcomes [21]. Tus, it is important to call for more attention and more resources for stroke. It is an urgent task around the world to increase economic investment, expand the coverage of medical insurance, and increase the proportion of reimbursement for major diseases such as stroke. Patients with high efciency in self-management are more likely to have better self-management behaviors. More and more studies have pointed out the importance of self-efcacy in the long-term care of people with enduring illnesses; patients with high efcacy function better in daily activities, perceive a better quality of life, and have worse emotional disorders than patients with low self-efcacy [22][23][24]. Among many theories on behavior change, Social Cognitive Teory emphasizes it is a multifaceted causal structure in which selfefcacy plays an important role in this process [25]. Actually sufering from stroke may be a traumatic experience for patients, it is a huge challenge for them. A study shows that perceived coping self-efcacy emerges as a focal mediator of posttraumatic recovery, which lends support to the centrality of the enabling and protective function of belief in one's capability to exercise some measure of control over traumatic adversity [26]. Nowadays, some interventions based on selfefcacy aiming at improving outcomes in stroke patients are showing up gradually [27][28][29]. Tus, we should explore more efective interventions to improve self-management efciency, especially for those needing long-term care diseases, eliminate the negative emotions and pessimistic attitude, so as to increase the possibility to change unhealthy lifestyle and improve self-management ability.
Patients who accepted the self-management health education before discharge may have better self-management behaviors. Health education is a continuous, dynamic, complex, and planned teaching process throughout the whole process of life [30]. Health education could help patients and their caregivers know the right knowledge about this disease and enhance their faith in changing bad behaviors. A study found that nurses can help improve patients' knowledge and cognition of the risks of stroke by playing the health education CD-ROM and providing printed information during the patients' wait time before appointments [31]. In our study, this question was reported by themselves, nearly half of the patients answered they didn't receive the content of stroke in hospital. On the one hand, patients may have a misperception due to low sensitivity and acceptance of health knowledge. On the other hand, the information we provided to patients they may don't need. However, providing health education about how to manage themselves before discharge is the theoretical basis for long-termin-home management. With the development of the times, more and more health education models emerged. Te health belief model is generally used to reduce the risk of developing a disease or manage an already existing disease. According to the health belief model, patients may change their behavior if they perceive a health threat [32]. Besides, social cognitive theory also posits that health behaviour is determined by the interaction of personal cognitive factors, socioenvironmental factors, and behavioral factors [33]. Terefore, we should formulate the content and form of health education under the guidance of these health education theories, taking into account the patients' cognitive, social, and economic factors, individual factors, and other specifc factors. Te form of health education is also changing with time; social media has now become a popular and broad way to do so as the world continues to advance technologically [34]. It is a global trend to transform traditional health education into digital   Age is an unalterable factor for self-management behavior; our study found that the elderly (age more than 60 years) may have better self-management behavior compared to the young (less than 44 years). Te elderly patients, especially the retired, have more time and energy to manage their own diseases. While the young who have a long life expectancy after stroke may consider return to the society more. It is hard for the young population to devote themselves to long-term rehabilitation as peers all working and taking family responsibilities. With an increasing incidence of stroke in young adults, the optimal and specifc management of this population needs more research studies.
In our study, patients with better limb function had better self-management behaviors than those who had a severer motor disability. Physical well-being seems to be the most afected component of quality of life. A review showed that the level of disability, presence of comorbidities, and motor function were the key predictors for quality of life among stroke survivors in Africa [35]. Te lives of patients with better limb function are less afected, which in turn will promote these patients to better implement self-management behavior. Naturally, patients with better limb function have fewer difculties with selfmanagement, so they can change their poor lifestyle and improve their self-management abilities faster. Nowadays, more and more studies are focusing on diferent interventions to improve the motor function of stroke   patients, including repetitive transcranial magnetic stimulation [36], virtual reality [37], mirror therapy [38], and so on. Within these felds, upper limb function is the most concerning.
In general, the self-management behavior among Chinese stroke patients is at the middle level. Te independent factors that afect the self-management behavior of stroke patients are: the payment way for medical expenses, SSEQ self-management efcacy, self-management health education before discharge, age (elderly), educational level, and mRS. It is not only necessary to popularize the knowledge of basic prevention and control of the disease, but it is also necessary to continuously encourage the patients to establish the determination and confdence to efectively control the disease and gradually improve self-efcacy, so as to change the unhealthy behaviors afecting health and fnally improve self-management ability.

Limitations
Tis study has some limitations. First, because the survey was fnished in one hospital, the representativeness of the samples was limited. Second, this study only investigated the score of mRS less than 3. Some patients with severe disabilities still have part of self-management ability, which needs further research to explore the self-management ability of patients with severe disabilities. Tird, the regression models we used may have several limitations in determining the risk factor of the given variable. Further studies may use a muticenter, large survey to verify our conclusion. If possible, use the SEMs to discover the severity and direction of the association between self-management and other factors.

Conclusions
Te self-management behavior of Chinese stroke patients is at the middle level. Patients with medical insurance, high self-management efciency, and better limb function may have better self-management behavior. Besides, patients with a high educational level who accept health education before discharge may also have better self-management behavior. It is important for patients to get knowledge about stroke in a right way and set up the faith to take care of themselves independently gradually. Furthermore, it is necessary and important for medical staf to give all patients health education about self-management before discharge and to increase the efectiveness of interventions for rehabilitation.

Data Availability
Te data that support the fndings of this study are available from the corresponding author.